Boy With Annular, Asymptomatic, Flesh-Colored Wrist Lesion

May 1, 2009

A 7-year-old boy with annular, asymptomatic, flesh-colored lesion onthe wrist that had developed slowly over the past month. The parents hadremoved the child from school because they were told that the lesion wasringworm. The lesion had failed to resolve after application of an antifungalcream for 10 days.

HISTORY
A 7-year-old boy with annular, asymptomatic, flesh-colored lesion on the wrist that had eveloped slowly over the past month. The parents had removed the child from school because they were told that the lesion was ringworm. The lesion had failed to resolve after application of an antifungal cream for 10 days.

PHYSICAL EXAMINATION
Apparently healthy child. Nontender plaque with slightly raised, hypopigmented outer edge noted on the wrist. Skin otherwise normal without scale, vesicles, or pustules. Remaining physical findings normal.

WHAT’S YOUR
DIAGNOSIS?
(Answer on next page)
ANSWER: LOCALIZED GRANULOMA ANNULARE


Granuloma annulare is a benign inflammatory skin disease characterized by annular plaques and dermal papules. Although several theories about its origin exist, the cause remains unknown.1 The female to male ratio is approximately 2:1. Granuloma annulare can occur at any age; however, the condition is most commonly seen in 2 age groups: children younger than 10 years and adults between the ages of 30 and 60 years.1 The lesions develop slowly and can remain for months or years. In about 50% of patients with localized granuloma annulare, spontaneous resolution occurs without sequelae within 2 years; however, recurrence is common.2
CLINICAL MANIFESTATIONS
The 5 clinical variants of granuloma annulare are listed in the Table. The most common forms of granuloma annulare-localized and generalized-typically develop as asymptomatic cutaneous lesions. They improve in the winter and worsen in summer. Lesions may be stable for months but may enlarge rapidly within a few weeks.1
DIAGNOSIS
Laboratory and imaging studies can help exclude other conditions; however, the diagnosis is generally clinical. Often, granuloma annulare is confused with a fungal infection or eczematous eruption, and the patient may have already attempted antifungal or corticosteroid treatment (Figure 1). Granuloma annulare can be distinguished from these and other skin conditions (such as pityriasis rosea, psoriasis, and erythema migrans) by the lack of scale and associated vesicles or pustules.

Biopsy is recommended for subcutaneous granuloma annulare (Figure 2) and for atypical lesions, ie, those that are painful, have rapidly enlarged, or are in an uncharacteristic location. Histological examination reveals foci of degenerative collagen associated with palisaded
granulomatous inflammation.2
MANAGEMENT
Many different treatment options are currently being explored for all 5 types of granuloma annulare.1 However, no treatment is strongly recommended for any of the clinical variants, because of the high likelihood of either resolution or recurrence despite therapy.

Localized lesions. Patients with localized granuloma annulare and their caregivers can be reassured that the lesion is benign and may spontaneously resolve, but they should be advised to return if they notice any rapid change in the character or size of the lesion. Recurrence,
often at the same site, is noted in 40% of cases.3 Painful or disfiguring localized granuloma annulare has been treated with varying results by several methods, including cryotherapy, a 4- to 6-week course of potent topical corticosteroids, and intralesional corticosteroids at varying doses.3
Generalized lesions. Generalized granuloma annulare tends to have a more chronic course; it rarely resolves spontaneously and typically recurs. Although the treatment of choice remains to be defined, first-line options for generalized granuloma annulare often include the use of isotretinoin or phototherapy with oral psoralen and UVA (PUVA). PUVA inhibits mitosis by bining covalently to pyrimidine bases in DNA when photoactivated by UVA.

Perforating lesions. Perforating granuloma annulare has been associated with diabetes in up to 17% of patients.4 Treatment with bath PUVA has been successful.5 However, most treatments have limited success. Topical or intralesional corticosteroids are effective in about half of cases, yet about one-third of cases spontaneously resolve. Topical tacrolimus ointment has also been used.6
Subcutaneous lesions. Subcutaneous granuloma may be removed via excisional biopsy, which is frequently required for definitive diagnosis. The lesions often spontaneously regress; however, local and distant recurrences have been reported in 20% to 75% of cases in different studies.7 The recurrences were typically characterized by multiple lesions and persistence for months to years. Progression to systemic disease has not been reported in patients with subcutaneous granuloma annulare.8Arcuate dermal erythema. This type of granuloma annulare essentially follows the same characteristics of the other types. It has a high resolution rate and responds to topical and intralesional corticosteroids. Some lesions may clear in response to biopsy.9


Figure 1 – Localized granuloma annulare on the legs of a 14-year-old girl. This asymptomatic eruption had been present for several months. The annular lesions had some central clearing and a raised erythematous border without scale. Localized granuloma annulare sometimes presents as a single lesion, and other times as multiple lesions. Just as with the boy in the featured case, this patient was presumed to have ringworm and was treated with antifungal cream; the treatment was unsuccessful. The diagnosis was confirmed via dermatological consultation. (Case and photograph courtesy of Edidiong C. Ntuen, MS, of Wake Forest University School of Medicine, and Barbara Wilson, MD, of University of Virginia Department of Dermatology.)


Figure 2 – Subcutaneous granuloma annulare on the third knuckle of a 15-year-old girl. This lesion had developed over the past 6 months and was asymptomatic (A). When the patient made a fist, the lesion became more prominent (B). A dermatological consultation confirmed the clinical diagnosis. Treatment with a topical corticosteroid was recommended. (Photographs courtesy of Robert P. Blereau, MD, of Morgan City, La.)




References:

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